1. Marc Hopkinson Gateshead Care Home Programme

2. Our Mission & Vision Mission: Working together to improve the health of Gateshead Vision:  Care for people in a seamless way  Ensure commissioning is clinically led and driven by patients and carer involvement  Improve the quality of health services Quality of Care Working together Compassion Improving Lives Respect & Dignity Everyone Counts

3. Needs increasing: scale Now 191,000 population 18% over 65 years 3.7% over 85 years 0.85% living in care homes Median length of stay 20 months (23 in Nursing, 27 in Residential) 2030 203,000 population Aged 65 + increase of 1/3 (34,000 – 45,000) Over 85 years - 90% increase (3,900 to 7,500)

4. Quality not right now Frailty is the issue Care is reactive … we need specialist proactive Variation e.g. multiple practices causes problems Communication issues across settings - admission/discharge Care planning inc advanced care (In and OOH)

5. Older People (40, 000 aged 65 +) Residential Care Homes 17 homes (596 patients) Nursing Homes 15 homes (907 patients) Specialist Care Homes (including Learning Disability, Promoting Independence Centres and Specialist Mental Health) Older People supported to live at home aged 65+ (4273 patients)

6. Aim: To improve the care of patients and families through more integrated proactive care

7. Objectives: Improve each care setting and bring them into a ‘frailty team’ Increasing skills and understanding in homes. Changing reactive primary care delivery to a proactive model involving weekly visits by a lead GP from the care homes linked practice Comprehensive care planning and MDT case management led by specialist nurses at the weekly ward rounds with ongoing support to homes

8. Objectives (Cont) Bringing specialists into a virtual team to support when needed and improving communication between Reduce avoidable hospital admissions To be cost saving

9. Case History – Reactive Care History 96 year old male with COPD from NH, previous NOF, non weight bearing, cognitive impairment, incontinent of urine Presentation Urgent care called as unwell – sats 69% pulse134 Admitted 18.00 ambulance MAU Assessment Diagnosed Urinary sepsis +/- chest sepsis Intervention Antibiotics and fluids Review next morning continue treatment but aim to keep comfortable Next day Liverpool care pathway Outcome 3.30 AM next day transferred ward 24 Died 6am following morning in hospital

10. Case History – Anticipatory Care History Alzheimers Disease Frequent admissions [9], Recurrent aspiration pneumonia Seizures [ drowsy on meds] Presentation Drowsy, not eating/drinking, weight loss Hypotensive, tachycardia Assessment Reviewed food/fluid charts – long term poor intake [500-1000mls/day] Rapid decline last 2 months …. functional change [in bed, posture, swallow] Family – reluctant for EOL planning, grief

11. Anticipatory Care (Cont) Intervention/Plan Hypernatraemia [169] all else NAD = dehydration Anticipatory care plan with GP - EOL discussions with husband – wishes to avoid admission Liaised with Geriatrician – plan educate staff/family to push oral fluids, monitor u&e’s Medication review Outcome Fluid Intake >2000mls daily maintained Health stabilised [ improved baselines, reduced admissions, ] MDT Input [SALT, Physio, OAP] – back in lounge, in chair, smiling, weight gain] Improved quality – interaction with family Clear anticipatory plan with EOL aims, 6 monthly planned reviews 1 further admission during pilot – shorter LOS

12. Pilot Results Investment of approx £50k 98 patients case managed 45.5% reduction in admission rates based on 2008/09 data - admission days 440 - admission costs £243,146 Savings assuming same conditions/reasons for admission for total care home population in Gateshead: - 6763 bed days - £3,730,446 ‘You gave me my father back’

13. Care home staff Specialist input (OAP, SALT, Physio) Outpatient geriatrician Inpatient Lead GP, Specialist Nurse Patients, Carers and families

14. Expanding this across Gateshead Care homes trained 28/34 Care homes linked to practices 6 specialist nurses proving comprehensive reviews, care planning, liaising and reactive care Medicines Management Team GHFT Geriatrician Laptops Key partners- LA, OA Psychiatry

15. Specialist Nurses Commissioned

17. The Project Group Dr Mark Dornan Lesley Bainbridge Lynne Shaw Dr Daniel Cowie Dr Louise Crabtree Marc Hopkinson

18. Any Questions? http://gatesheadccg.nhs.uk /about-us/case-studies/